Download THE EFFECT OF SPIRONOLACTONE ON LEFT

THE EFFECT OF SPIRONOLACTONE ON LEFT
VENTRICULEREMODELINGIN PATIENTS WITH ARTERIAL
HYPERTENSION AND CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
DielievskaV.Yu.
Kharkiv National Medical University, Kharkiv, Ukraine
Introduction
It is believed that myocardial remodeling in response to the left ventricle (LV) overload helps to
support adequate pumping function of the heart. Known types of left ventricle remodeling are the
results of different types of hemodynamic overload. Chronic pressure overload (increased after
load) leads to concentric remodeling of myocardium by developing more parallel spaced sarcomers.
Chronic blood volume overload causes development of eccentric left ventricle hypertrophy, which
manifests by its dilatation without significant thickening of the walls. This occurs because the
increased blood volume (increased preload) enhances pressure on left ventricle walls, which leads
to the changed length of the muscle cells with an increase on LV cavity. The search for the drugs
that are able to slow down the development of myocardial hypertrophy and lead to its reverse
remodeling is up to date. In the literature there are promising data of aldosterone antagonists
possibilities in reducing myocardial hypertrophy and risk of cardiovascular events [1].
Today the combination of arterial hypertension (AH) and chronic obstructive pulmonary disease
(COPD) creates mutual burden that leads to an increased risk of death from cardiovascular
complications in 2-3 years [2]. Since it is believed that the presence of LV remodeling is enough for
the progression of heart failure regardless of the neurohormonal status of the patient, and that
concentric hupertrophy of LV has the highest risk of cardiovascular complications among other
types of myocardial remodeling [3], of interest is to determine the geometry of the LV in patients
with AH in combination with COPD and to evaluate therapeutic opportunities of using
spironolactone in reverse remodeling of LV.
The objective – to study the effictiveness of spironolactone in reverse remodeling of
the LV in patients with (AH) in combination with COPD.
Material and methods
60 patients with II stage of AH and COPD of II-III degree of bronchial obstruction
(GOLD 2-3) were examined. The first group consisted of 28 patients with AH and GOLD 2-3
(17 men and 11 women, mean age 67,11 ± 1,52) were treated with standard therapy of COPD
and AH using β2-agonists, corticosteroids, anticholinergics, ACE inhibitors and diuretics. The
second group consisted of 32 people (19 men and 13 women, mean age 54,32 ± 2,2) with AH
and GOLD 2-3, which in addition to standard therapy were treated with spironolactone in a
dose of 50 mg per day for 3 months. All the patients underwent general clinical and
biochemical investigations, spirometry and echocardiography.
Results
Analysis of the distribution of the patients according to the type of remodeling of LV
(according to Ganau A. et al. (1992) classification) revealed, that the most common type was
concentric hypertrophy of LV – in 80 % of patients with AH and GOLD 2, and in 56 % of
patients with AH and GOLD 3. It was followed by eccentric hypertrophy – in 13 % of
patients with AH and GOLD 2 and in 36 % of patients with AH and GOLD 3. Meanwhile
concentric remodeling was present in 6 % of patients with AH and GOLD 2 and in 10 % of
patients with AH and GOLD 3.
To understand the influence of bronchial obstruction on the main parameters of LV
remodeling – left ventricular myocardial mass (LVMM) and relative wall thickness (RWT) – in
patients with AH and COPD we performed correlation analysis by Spirmen with above
mentioned parameters and lung function data(Table1).
Table 1 – Correlation between some parameters of lung function and left ventricular
myocardial mass and relative wall thickness in patients with arterial hypertension in
combination with COPD
Note: * – р<0,05.
Thus, we received, that enhancing of the bronchial obstruction degree in patients with
AH and COPD promotes LVMM and RWT increase, thus contributing to the worst type of
LV remodeling – concentric hypertrophy of LV.
After the basic treatment of heart failure patients with AH and GOLD 2 almost did not
change LV geometry – 11 (78 %) patients showed concentric hypertrophy of LV, 1 (7 %) –
eccentric hypertrophy of LV and 2 (14 %) patients – concentric remodeling. After the basic
treatment with spironolactone only half of the patients with AH and GOLD 2 presented
concentric hypertrophy of LV (8 (50 %)), (7 (43 %) patients showed concentric remodeling
and 1 (6 %) patients had normal LV geometry. No patients presented eccentric hypertrophy of
LV.
Presentation of LV remodeling types in patients with AH and GOLD 3 after basic
treatment was also slightly changed. 9 (64 %) of patients showed concentric hypertrophy of
LV, 4 (28 %) patients – eccentric hypertrophy of LV and 1 (7 %) patient – concentric
remodeling. Another situation was observed after adding spironolactone to the basic therapy
in patients with AH and GOLD 3. The percentage of the most unfavourable type of LV
remodeling – concentric hypertrophy of LV was reduced on 19 % and the percentage of
patients with the most favorable type of LV remodeling – concentric remodeling – was
increased by 19 %. The percentage of the patients with eccentric hypertrophy of LV did not
change and comprised 5 patients (31 %).
It is well known, that compensatory LV hypertrophy is an established risk factor for
atrial fibrillation, diastolic and systolic heart failure and sudden death. So decrease of the
number of patients with LV hypertrophy in AH and COPD using aldosterone antagonist will
have significant positive effect on cardivascular prognosis.
Conclusions
Thus, adding spironolactone to the basic treatment of heart failure in patients with AH and COPD
leads to positive structural, functional and hemodynamic changes, prevents further adverse
remodeling of the cardiovascular system and the progression of cardiac dysfunction. Additional use
of spironolactone provides decrease of concentric LV hypertrophy and reappearance of normal LV
geometry that agrees with the data of other researchers.
References
1. Masaki, T. Spironolactone alleviates late cardiac remodeling after left ventricular restoration
surgery. /T. Masaki, M. Akira, N. Takeshi //J. Thorac. Cardiovasc. Surg. – 2008. – № 136 –
P. 58–64.
2. Macnee, W. Cardiovascular injury and repair in chronic obstructive pulmonary disease
/ W. Macnee, J. Maclay, D. McAllister // Proceedings of the American Thoracic Society. –
2008. – № 5. – P. 824–833.
3. Concentric left ventricular hypertrophy as independent predictor of 1-year rehospitalization
and mortality in patients hospitalized for acute heart failure and preserved ejection fraction.
/ L. Zhong [et al.] // J. Am. Coll. Cardiol. – 2012. – № 59. – P. e854.